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APPENDIX H – HICS FORMS

Appendix HHICS Forms

Form # Form Title

200 Incident Act i on Plan (IAP) Cover Sheet

IAP Quick Start

Incident Act i on Plan (IAP) Quick Start

201 Incident Br i e fing

202 Incident Objectives

203 Organization Assignment List

204 Assignment List

205A Communications List

206 Staff Medical Plan

207 Hospital Incident Management Team (HIMT) Chart

213 General Message Form

214 Activity Log

215A Incident Act i on Plan (IAP) Safety A n a l ysis

221 Demobilization Chec k Out‐

251 Facili t y Sys t em Status R e port

252 Section Per s onnel Timesheet

253 Volunteer Registration

254 Disaster Victim/Patient Tracking

255 Master Patient Evacuat i on Tracking

256 Procureme n t Summary Report

H ‐ 1

APPENDIX H – HICS FORMS

Form # Form Title

257 Resource Accounting Record

258 Hospital Re s o urc e Direc t ory

259 Hospital Casualty/Fatali t y Report

260 Patient Evacuation Tracking

H ‐ 2

HICS 200 - INCIDENT ACTION PLAN (IAP) COVER SHEET

1. Incident Name 2. Operational Period (# )

DATE: FROM: _ TO: _

TIME: FROM: TO:

3. Attachments The items checked below are included in this Incident Action Plan (IAP)

Incident Action Plan (IAP) Quick Start

or

HICS 201 - Incident Briefing

HICS 202 - Incident Objectives

HICS 203 - Organization Assignment List

HICS 204 - Assignment List

HICS 204 - Assignment List; Operations Section: Staging

HICS 204 - Assignment List; Operations Section: Medical Care Branch

HICS 204 - Assignment List; Operations Section: Infrastructure Branch

HICS 204 - Assignment List; Operations Section: Security Branch

HICS 204 - Assignment List; Operations Section: HazMat Branch

HICS 204 - Assignment List; Operations Section: Business Continuity Branch

HICS 204 - Assignment List; Operations Section: Patient Family Assistance Branch

HICS 204 - Assignment List; Planning Section

HICS 204 - Assignment List; Logistics Section: Service Branch

HICS 204 - Assignment List; Logistics Section: Support Branch

HICS 204 - Assignment List; Finance/Administration Section

HICS 215A - Incident Action Plan (IAP) Safety Analysis

Other: _

Other: 4. Prepared by PRINT NAME: SIGNATURE: _

Planning Section ChiefDATE/TIME: FACILITY:

5. Approved by PRINT NAME: _ SIGNATURE:

Incident CommanderDATE/TIME: FACILITY:

Purpose: Provide cover sheet and checklist for HICS Forms and other documents included in the Operational Period Incident Action Plan (IAP)Origination: Incident Commander or Planning Section Chief

Copies to: Command Staff, Section Chiefs, and Documentation Unit LeaderHICS 200 | Page 1 of 1

HICS 200 - INCIDENT ACTION PLAN (IAP) COVER SHEET

PURPOSE: The HICS 200 – Incident Action Plan (IAP) Cover Sheet provides a cover sheet and a checklist for HICS Forms and other documents included in the operational period IAP.

ORIGINATION: Prepared by the Incident Commander or Planning Section Chief.

COPIES TO: Duplicated and distributed to Command and General Staff positions activated. All completed original forms must be given to the Documentation Unit Leader.

NOTES: If additional pages are needed for any form page, use a blank HICS 200 and repaginate as needed. Additions may be made to the form to meet the organization’s needs.

NUMBER TITLE INSTRUCTIONS

1 Incident Name Enter the name assigned to the incident.

2 Operational Period Enter the start date (m/d/y) and time (24-hour clock) and end date and time for the operational period to which the form applies.

3 Attachments Check or list all HICS Forms and other documents that are included in the Incident Action Plan (IAP).

4 Prepared byPlanning Section Chief

Enter the name and signature of the person preparing the form. Enter date (m/d/y), time prepared (24-hour clock), and facility.

5 Approved byIncident Commander

Enter the name and signature of the person approving the form. Enter date (m/d/y), time prepared (24-hour clock), and facility.

HICS 2014

HICS INCIDENT ACTION PLAN (IAP) QUICK STARTCOMBINED HICS 201—202—203—204— 215A


DATE: FROM: TO: _

TIME: FROM: TO:

3. Situation Summary — H ICS 201 —

4. Current Hospital Incident Management Team (f ill in additional positions as appropriate) — H ICS 201, 203 —

Public Information OfficerIncident Commander

Medical-Technical SpecialistsLiaison Officer

Safety Officer

Operations Planning Logistics Finance / AdministrationSection Chief Section Chief Section Chief Section Chief

Purpose: Short form combining HICS Forms 201, 202, 203, 204, and 215AOrigination: Incident Commander or Planning Section ChiefCopies to: Command Staff, Section Chiefs, and Documentation Unit Leader

IAP Quick Start | Page 1 of 2

HICS INCIDENT ACTION PLAN (IAP) QUICK STARTCOMBINED HICS 201—202—203—204— 215A

5. Health and Safety Briefing Identify y potential incident health and safety hazards and develop necessary measures (remove hazard, provide personal protective equipment, warn people of the hazard) to protect responders from those hazards. — H ICS 202, 215A —

6. Incident Objectives — H ICS 202, 204 —

6a. OBJECTIVES 6b. STRATEGIES / TACTICS 6c. RESOURCES REQUIRED 6d. ASSIGNED TO

7. Prepared by PRINT NAME: _ SIGNATURE:

DATE/TIME: _ FACILITY:

Purpose: Short form combining HICS Forms 201, 202, 203, 204, and 215AOrigination: Incident Commander or Planning Section ChiefCopies to: Command Staff, Section Chiefs, and Documentation Unit Leader

IAP Quick Start | Page 2 of 2

HICS INCIDENT ACTION PLAN (IAP) QUICK STARTCOMBINED HICS 201—202—203—204—215A

PURPOSE: The Incident Action Plan (IAP) Quick Start is a short form combining HICS Forms 201, 202,203, 204 and 215A. It can be used in place of the full forms to document initial actions taken or during a short incident. Incident management can expand to the full forms as needed.

ORIGINATION: Prepared by the Incident Commander or Planning Section Chief.

COPIES TO: Duplicated and distributed to Command and General Staff positions activated. All completed original forms must be given to the Documentation Unit Leader.

NOTES: If additional pages are needed for any form page, use a blank HICS IAP Quick Start and repaginate as needed. Additions may be made to the form to meet the organization’s needs.




3 Situation Summary Enter brief situation summary.

4 Current HospitalIncident ManagementTeam

Enter the names of the individuals assigned to each position on the Hospital Incident Management Team (HIMT) chart. Modify the chart as necessary, and add any lines/spaces needed for Command staff assistants, agency representatives, and the organization of each of the General staff sections.

5 Health and SafetyBriefing

Summary of health and safety issues and instructions.

6 Incident Objectives6a. Objectives Enter each objective separately. Adjust objectives for each

operational period as needed.

6b. Strategies / Tactics For each objective, document the strategy/tactic to accomplish that objective.

6c. Resources Required For each strategy/tactic, document the resources required to accomplish that objective.

6d. Assigned to For each strategy/tactic, document the Branch or Unit assigned to that strategy/tactic.

7 Prepared by Enter the name and signature of the person preparing the form. Enter date (m/d/y), time prepared (24-hour clock), and facility.

HICS 2014

HICS 201 - INCIDENT BRIEFING


DATE: FROM: TO:

TIME: FROM: _ TO:

3. Situation Summary (f or briefings or transfer of command)

4. Health and Safety Briefing Identify potential incident health and safety hazards and implement necessary measures (remove hazard, provide personal protective equipment, warn people of the hazard) to protect responders from those hazards. (Summary of HICS 215A)

5. Map / Sketch (Attach sketch showing the total area of operations, the incident site/area, impacted and threatened areas, and/or other graphics depicting situational status and resource assignment, as needed.)

See Attached

Purpose: Basic information regarding the incident situation and resources allocatedOrigination: Incident CommanderCopies to: Command Staff, Section Chiefs, and Documentation Unit Leader

HICS 201 | Page 1 of 4


6. Current Hospital Incident Management Team (f ill in additional positions as appropriate)

Public Information OfficerIncident Commander (s )

Medical-Technical Specialists

Liaison Officer

Safety Officer

OperationsSection Chief

PlanningSection Chief

LogisticsSection Chief

Finance / AdministrationSection Chief

Staging Manager ResourcesUnit Leader

ServiceBranch Director

TimeUnit Leader

Medical CareBranch Director

SituationUnit Leader

SupportBranch Director

ProcurementUnit Leader

Infrastructure BranchDirector

DocumentationUnit Leader

Compensation / Claims Unit Leader

SecurityBranch Director

DemobilizationUnit Leader

CostUnit Leader

HazMatBranch Director

Business ContinuityBranch Director

Patient Family Assistance Branch

Director




7. Incident Objectives

8. Summary of Current and Planned Actions

TIME ACTIONS




9. Summary of Resources Requested and Assigned

RESOURCEDATE / TIME ORDERED

ETADATE / TIME

ARRIVED

NOTES(LOCATION / ASSIGNMENT / STATUS)

10. Prepared by Incident Commander PRINT NAME: ____________________________________________________________ SIGNATURE: _________________________________________________

BRIEFING DATE/TIME: _________________________________________________ FACILITY: ____________________________________________________




PURPOSE: The HICS 201 – Incident Briefing provides the Incident Commander and the Hospital Incident Management Team (HIMT) with basic information regarding the incident, current situation, and the resources allocated to the response.

ORIGINATION: Prepared by the Incident Commander for presentation to the staff or later to the incomingIncident Commander along with a detailed oral briefing.

COPIES TO: Duplicate and distribute before the initial briefing of the Command and General Staff or other responders as appropriate. All completed original forms must be given to the Documentation Unit Leader.

NOTES: If additional pages are needed for any form page, use a blank HICS 201 and repaginate as needed. Additions may be made to the form to meet the organization’s needs.




3 Situation Summary Concise statement of the status and information regarding the current situation.

4 Health and SafetyBriefing

Enter the summary of health and safety issues and instructions.

5 Map / Sketch Attach as necessary: floor plans, maps, sketches of impacted area, or response diagrams. North should be at the top of the page unless noted otherwise.

6 Current Hospital IncidentManagement Team

Enter the names of the individuals assigned to each position directly onto the Hospital Incident Management Team (HIMT) chart. If Unified Command is being used, split the Incident Commander box and indicate agency for each of the Incident Commanders listed.

7 Incident Objectives Enter the objectives used for the incident.

8 Summary of Current andPlanned Actions

Enter the current and planned actions and time (24-hour clock) they may or did occur. If additional pages are needed, use a blank sheetor another HICS 201 (page 3), and adjust page numbers accordingly.

9 Summary of ResourcesRequested and Assigned

Enter information about the resources allocated to the incident. If additional pages are needed, use a blank sheet or another HICS 201 (page 4), and adjust page numbers accordingly.

Resource Enter the number and category, kind, or type of resource ordered.

Date / Time Ordered Enter the date (m/d/y) and time (24-hour clock) the resource was ordered.

ETA Enter the estimated time of arrival (ETA) to the incident (24-hour clock).

Date / Time Arrived Enter the date (m/d/y) and time (24-hour clock) the resource arrived.

Notes Enter notes such as the assigned location of the resource and/or the actual assignment and status.

10 Prepared byIncident Commander


HICS 2014

HICS 202 - INCIDENT OBJECTIVES


DATE: FROM: TO:

TIME: FROM: TO:

3. Incident Objectives

4. Factors to Consider Considerations in relationship to the objectives and priorities, including weather and situational awareness.

5. HICS 215A - Incident Action Safety Analysis and / or Site Safety Plan? YES NO

Approved Site Safety Plan Locations:

6. Prepared by PRINT NAME: SIGNATURE:

Planning Section ChiefDATE/TIME: FACILITY:

7. Approved by PRINT NAME: SIGNATURE:

Incident CommanderDATE/TIME: FACILITY:

Purpose: Describes Basic incident objectives and safety considerationsOrigination: Planning Section

Chief Copies to: Command Staff, Section Chiefs, and Documentation Unit Leader


HICS 202 - INCIDENT OBJECTIVES

PURPOSE: The HICS 202 - Incident Objectives describes the basic incident strategy, incident objectives, command priorities, and safety considerations for use during the next operational period.

ORIGINATION: Completed by the Planning Section Chief for each operational period as part of the Incident Action Plan (IAP) and approved by the Incident Commander.

COPIES TO: May be reproduced with the IAP and given to Command Staff, Section Chiefs, and all supervisory personnel at the Section, Branch, and Unit levels. All completed original forms must be given to the Documentation Unit Leader.

NOTES: If additional pages are needed, use a blank HICS 202 and repaginate as needed. Additions may be made to the form to meet the organization’s needs.

NUMBER TITLE INSTRUCTIONS1 Incident Name Enter the name assigned to the incident.


3 Incident Objectives Enter clear, concise statements of the objectives for managing the response. Ideally, these objectives will be listed in priority order. These objectives are for the incident response for this operational period as well as for the duration of the incident. Include alternative and/or specific tactical objectives as applicable.

4 Factors to Consider Enter considerations for the operational period, which may include tactical priorities or a general situational awareness for theoperational period. It may be a sequence of events or order of events to address. General situational awareness may include a weather forecast, incident conditions, and/or a general safety message. If a safety message is included here, it should be provided by the Safety Officer.

5 HICS 215A or Site SafetyPlan Required

Safety Officer should check whether or not a Site Safety Plan is required for this incident.

Approved Site Safety PlanLocations

Enter the locations of the approved Site Safety Plan.

6 Prepared by PlanningSection Chief


7 Approved by IncidentCommander

If additional Incident Commander signatures are required, attach a blank page. Enter date (m/d/y), time prepared (24-hour clock), and facility.

HICS 2014

HICS 203 – ORGANIZATION ASSIGNMENT LIST


DATE: FROM: TO:

TIME: FROM: TO: _____

POSITION NAME CONTACT INFO (PHONE, CELL, RADIO)

3. Incident Commander(s) and Staff

Incident Commander

Public Information Officer

Liaison Officer

Safety Officer

Medical-Technical Specialist:




4. Operations Section

Operations Chief

Staging Manager

Medical Care Branch Director

Infrastructure Branch Director

Security Branch Director

Hazardous Materials Branch Director

Business Continuity Branch Director

Patient Family Assistance Director

Others if needed

5. Planning Section

Planning Chief

Resources Unit Leader

Situation Unit Leader

Documentation Unit Leader

Demobilization Unit Leader

6. Logistics Section

Logistics Chief

Service Branch Director

Support Branch Director

7. Finance / Administration Section

Finance/Administration Chief

Time Unit Leader

Procurement Unit Leader

Compensation/Claims Unit Leader

Cost Unit Leader

8. Agency Executive

9. External Agency Representative(in the Hospital Command Center)

10. Hospital Representative (in the externalEmergency Operations Center)

PRINT NAME: SIGNATURE: _11. Prepared by


Purpose: List person assigned to Hospital Incident Management Team (HIMT) positionOrigination: Planning Section Chief or designee (Resources Unit Leader)Copies to: Command Staff, Section Chiefs, Branch Directors, and Documentation Unit Leader


HICS 203 – ORGANIZATION ASSIGNMENT LIST

PURPOSE: The HICS 203 - Organization Assignment List provides Hospital Incident Management Team (HIMT) personnel with information on the positions that are currently activated and the names of personnel staffing each position.

ORIGINATION: The Planning Section Chief or designee (Resources Unit Leader) prepares and maintains the currency of the list. Complete only the blocks for the positions that are activated for the incident. If a trainee is assigned to a position, indicate this with a “T” in parentheses behindthe name (e.g., “A. Smith (T)”).

COPIES TO: Duplicate and provide to all recipients as part of the Incident Action Plan (IAP). All completed original forms must be given to the Documentation Unit Leader.

NOTES: For all individuals, use at least the first initial and last name. If there is a shift change or other reason during the specified operational period, list both names, separated by a slash.If assigned, document Assistants / Deputies to Command Staff as needed or resources allow. If additional pages are needed for any form page, use a blank HICS 203 and repaginate as needed. Additions may be made to the form to meet the organization’s needs.



3 Incident Commander(s)and Command Staff

Enter the names and contact information. For Unified Command, also include agency names.

4 Operations Section Enter the names and contact information.

5 Planning Section Enter the names and contact information.

6 Logistics Section Enter the names and contact information.

7 Finance / AdministrationSection

Enter the names and contact information.

8 Agency Executive Enter the name and contact information of the executive (e.g., Chief Executive Officer) with whom the Incident Commander interfaces.

9 External AgencyRepresentative

Enter the external agency/organization names present in the Hospital Command Center (HCC) and the names of their representatives.

10 Hospital Representative Enter the names and role of hospital personnel in the local emergency operations center (EOC), and local EOC location.


HICS 2014

HICS 204 - ASSIGNMENT LIST


DATE: FROM: _ TO: _

TIME: FROM: _ TO: _

3. Section

Section Chief

4. Branch (if applicable )

Branch Director

5a. Branch / Unit Related Objectives 5b. Strategies / Tactics 5c. Resources Required 5d. Unit Assigned to

Purpose: Documents strategies/tactics of each Section or Branch, resources to accomplish them, and the composition of the Unit assignedOrigination: Each Section Chief and Branch Director activatedCopies to: Command Staff, Section Chiefs, and Documentation Unit Leader



6. Unit(s) Assigned this Operational PeriodUnit Name Unit Name Unit Name Unit Name Unit Name Unit Name

Leader Name Leader Name Leader Name Leader Name Leader Name Leader Name

Unit Location Unit Location Unit Location Unit Location Unit Location Unit Location

Unit Members / Teams Unit Members / Teams Unit Members / Teams Unit Members / Teams Unit Members / Teams Unit Members / Teams

7. Special Information / Considerations

8. Prepared by PRINT NAME: SIGNATURE: _

DATE/TIME: FACILITY: _

Purpose: Documents strategies/tactics of each Section or Branch, resources to accomplish them, and the composition of the Unit assignedOrigination: Each Section Chief and Branch Director activatedCopies to: Command Staff, Section Chiefs, and Documentation Unit Leader



PURPOSE: The HICS 204 - Assignment List documents the strategies and tactics of each (activated) Section or Branch, the resources required, and the composition of the Unit assigned.

ORIGINATION: Prepared by the individual Section Chiefs or Branch Directors and submitted to thePlanning Section as part of the Incident Action Plan (IAP).

COPIES TO: Duplicate and attach as part of the IAP. All completed original forms must be given to the Documentation Unit Leader.

NOTES: If additional pages are needed, use a blank HICS 204 and repaginate as needed.Additions may be made to the form to meet the organization’s needs.




3 Section Enter the name of the Section and Section Chief.

4 Branch Enter the name of the Branch and Branch Director, if the form is for a specific Branch.

5 5a. Branch / UnitRelated Objectives

Utilizing the Incident Objectives (from HICS 202), develop objectives as they relate to the Branch/Unit. Enter objectives the Branch/Unit needs to focus on for the designated operational period.

5b. Strategies / Tactics For each objective, document the strategies/tactics to accomplish that objective.

5c. Resources Required For each strategy/tactic, document the resources required to accomplish that objective.

5d. Unit Assigned to For each strategy/tactic, document the Unit assigned to that strategy/tactic.

6 Unit(s) Assigned thisOperational Period

Enter the names of the Units activated, the name of the Unit Leader, location of the Unit, and the names of the members and/or teams making up the Unit.

7 Special Information / Considerations

Enter a statement noting any safety problems, specific precautions to be exercised, drop-off or pick-up points, or other important information.


HICS 2014

HICS 205A - COMMUNICATIONS LIST


DATE: FROM: TO:

TIME: FROM: TO:

3. Internal Contacts

ASSIGNMENT / NAME RADIO CH # / FREQUENCY PHONE FAX EMAIL MOBILE PHONE PAGER IDENTIFICATION NUMBER OF DEVICE

ISSUED / COMMENTS

4. Special Instructions

Purpose: Provides information on all communication devices assignedOrigination: Communications Unit LeaderCopies to: Command Staff, Section Chiefs, and Documentation Unit Leader

HICS 205A | Page 1 of 2


5. External ContactsAGENCY / ASSIGNMENT /

NAMERADIO CH # / FREQUENCY TELEPHONE FAX EMAIL MOBILE PHONE PAGER IDENTIFICATION NUMBER OF

DEVICE ISSUED / COMMENTS


7. Prepared byCommunications Unit Leader PRINT NAME: SIGNATURE:


Purpose: Provides information on all communication devices assignedOrigination: Communications Unit LeaderCopies to: Command Staff, Section Chiefs, and Documentation Unit Leader



PURPOSE: The HICS 205A - Communications List provides information on all radio frequencies, telephone, and other communication assignments for each operational period.

ORIGINATION: Prepared by the Logistics Section Communications Unit Leader and given to thePlanning Section Chief for inclusion in the Incident Action Plan (IAP).

COPIES TO: Duplicate and provide to all recipients as part of the IAP. All completed original forms must be given to the Documentation Unit Leader. Information from the HICS 205A can be placed on the

Organization Assignment List (HICS 203).

NOTES: If additional pages are needed, use a blank HICS 205A and repaginate as needed. Additions may be made to the form to meet the organization’s needs.


2 Operational Period Enter the start date (m/d/y) and time (using the 24-hour clock) and end date and time for the operational period to which the form applies.

3 Internal Contacts Enter the appropriate contact information for internal contacts, hospital personnel, those in an activated Hospital Incident Management Team (HIMT) position, and other key staff.

4 Special Instructions Enter any special instructions (e.g., using repeaters, secure-voice, private line [PL] tones, etc.) or other emergency communications. If needed, also include any special instructions for alternate communication plans.

5 External Contacts Enter the appropriate contact information for external agencies, organizations, key contacts.

6 Special Instructions Enter any special instructions (e.g., using repeaters, secure-voice, private line [PL] tones, etc.) or other emergency communications. If needed, also include any special instructions for alternate communication plans.

7 Prepared by Communications Unit Leader


HICS 2014

HICS 206 - STAFF MEDICAL PLAN1. Incident Name 2. Operational Period (# )

DATE: FROM: TO:

TIME: FROM: _ TO: _

3. Treatment Areas

AREA NAME LOCATIONUNIT / TEAM LEADER

CONTACT NUMBER / CHANNEL

4. Resources On Hand (numbers)STAFF TRANSPORTATION DEVICES MEDICATION SUPPLIES

MD/DO LITTERS

PA/NP PORTABLE BEDS

RN/LPN GURNEYS

TECHNICIANS/CAN WHEELCHAIRS

ANCILLARY/OTHER EVAC. ASSIST DEVICES

5. Transportation (indicate air or ground)AMBULANCE, BUS, VAN,

PRIVATE VEHICLE, AIR LOCATION CONTACT NUMBER / FREQUENCY LEVEL OF SERVICE

ALS BLS

ALS BLS

ALS BLS

ALS BLS

ALS BLS

6. Alternate Care Site(s)

FACILITY NAME ADDRESS CONTACT NUMBER / FREQUENCYSPECIALTY CARE

(SPECIFY)


8. Prepared byPRINT NAME: SIGNATURE: _

DATE/TIME: __________ FACILITY:

9. Approved byPRINT NAME: SIGNATURE: _

DATE/TIME: __________ FACILITY:

Purpose: Provides information on staff treatment areasOrigination: Employee Health and Well-Being Unit LeaderCopies to: Command Staff, Section Chiefs, and Documentation Unit Leader HICS 206 | Page 1 of 1

HICS 206 - STAFF MEDICAL PLAN

PURPOSE: The HICS 206 - Staff Medical Plan addresses the treatment plan for injured or ill staff members and / or volunteers. The HICS 206 provides information on staff treatment areas, resources on-hand, transportation services, and special instructions.

ORIGINATION: Prepared by the Logistics Section Employee Health and Well-Being Unit Leader

COPIES TO: Duplicate and provide to all recipients as part of the Incident Action Plan (IAP). Information from the plan pertaining to staff treatment areas and special instructions may be notedon the Assignment List (HICS 204). All completed original forms must be given to theDocumentation Unit Leader.




3 Treatment Areas Enter the name of the treatment area, the location, and the contact numbers.

4 Resources On Hand Enter the number of listed resources that are available and assigned to the treatment areas.

5 Transportation Enter the information for transportation services available to the incident.

6 Alternate Care Site(s) Enter the information for alternate care sites that could serve this incident.

7 Special Instructions Note any special emergency instructions for use by incident personnel, including who should be contacted, how should they be contacted; and who manages an incident within an incident due to a rescue, accident, etc.

8 Prepared by Enter the name and signature of the person preparing the form, typically the Employee Health and Well-Being Unit Leader. Enter date (m/d/y), time prepared (24-hour clock), and facility.

9 Approved by Enter the name of the person who approved the plan. Enter date (m/d/y), time reviewed (24-hour clock), and facility.

HICS 2014

HICS 207 - HOSPITAL INCIDENT MANAGEMENT TEAM (HIMT) CHART


DATE: FROM: TO:

TIME: FROM: TO:

4. Current Hospital Incident Management Team (fill in additional positions as appropriate)

Public Information Officer

Incident Commander Medical-Technical Specialists

Biologic/Infectious Disease Chemical Radiological Clinic Administration Hospital Administration Legal Affairs Risk Management Medical Staff Pediatric Care Medical Ethicist

Liaison Officer

Safety Officer

Operations Section Chief Planning Section Chief Logistics Section Chief Finance/Administration Section Chief

Staging Manager

Medical Care Branch Director

Personnel Staging Team Leader Vehicle Staging Team Leader Equipment/Supply Staging Team Leader

Medication Staging Team Leader

Inpatient Unit Leader Outpatient U nit Leader Casualty Care U nit Leader Behavioral Health U nit Leader Clinical Support Unit Leader Patient Registration Unit Leader

Resources Unit Leader

Situation Unit Leader

Personnel Tracking Manager Materiel Tracking Manager

Service

Branch Director

Communications U nit Leader IT/IS Equipment U nit Leader Food Services Unit Leader

Support Branch Director

Time Unit Leader

Procurement Unit Leader

Infrastructure Branch Director

Power/Lighting Unit Leader Water/Sewer U nit Leader HVAC Unit Leader Building/G rounds U nit Leader Medical Gases Unit Leader

Documentation Unit Leader

Patient Tracking Manager Bed Tracking Manager

Employee Health & Well-‐Being Unit Leader Supply U nit Leader Transportation Unit Leader Labor Pool & Credentialing Unit Leader

Employee Family Care Unit Leader

Compensation/ Claims Unit Leader

Security Branch Director

Access Control Unit Leader Crowd Control Unit Leader Traffic C ontrol U nit Leader Search Unit Leader

Law Enforcement Interface Unit Leader

Demobilization Unit Leader

Cost Unit Leader

HazMat Branch Director

Detection & Monitoring Unit Leader Spill Response Unit Leader

Victim Decontamination U nit Leader Facility/Equipment Decontamination Unit Leader

Business Continuity Branch Director

IT Systems and Applications Unit Leader Services C ontinuity Unit Leader Records Management Unit Leader

Patient Family AssistanceBranch Director

Social Services Unit Leader Family Reunification Unit Leader Purpose: Display positions assigned to Hospital Incident Management Team (HIMT)

Origination: Incident Commander or designeeCopies to: Command Staff, Section Chiefs, Documentation Unit Leader, and posted in the Hospital

Command Center (HCC)


HICS 207 - HOSPITAL INCIDENT MANAGEMENT TEAM (HIMT) CHART

PURPOSE: The HICS 207 – Hospital Incident Management Team (HIMT) Chart provides a visual display of personnel assigned to the HIMT positions.

ORIGINATION: Prepared by the Incident Commander or designee (Resources Unit Leader) at the incident onset and continually updated throughout an incident.

COPIES TO: Distributed to the Command and General Staff and the Documentation Unit Leader.The HICS 207 is intended to be projected or wall mounted at the Hospital CommandCenter (HCC) and is not intended to be part of the Incident Action Plan (IAP).

NOTES: Additions may be made to the form to meet the organization’s needs. Additional pages may be added based on need (such as to distinguish more branches or units as they are activated). Three versions of the HIMT Chart are available in the 2014Hospital Incident Command System (HICS) Appendix C: Adobe Acrobat fillable PDF, Microsoft Word, and Microsoft Visio Drawing.



3 Current Hospital Incident Management Team Chart

Enter the names of the individuals assigned to each position on the Hospital Incident Management Team (HIMT) chart. Modify the chart as necessary, and add any lines/spaces needed for Command Staff assistants, agency representatives, and the organization of each of the General Staff sections.

HICS 2014

HICS 213 - GENERAL MESSAGE FORM

1. Incident Name

2. ToPRINT NAME: POSITION: ___

3. FromPRINT NAME: POSITION: _

4. Subject 5. Date 6. Time

7. Priority URGENT - HIGH NON URGENT - MEDIUM INFORMATIONAL - LOW

8. Message RESPONSE REQUIRED

9. Approved by PRINT NAME: SIGNATURE:

10. Reply / Action Taken

11. Replied by PRINT NAME: SIGNATURE:

POSITION: FACILITY: _____

DATE/TIME:

.

Purpose: Used to transmit messages regarding resources requested, status information, and other coordination issuesOrigination: Any personnel HICS 213 I Page 1 of 1Copies to: Documentation Unit Leader

HICS 213 - GENERAL MESSAGE FORM

PURPOSE: The HICS 213 - General Message Form is used to record incoming messages that cannot be orally transmitted to the intended recipients. The HICS 213 is also used to transmit messages (resource order, status information, other coordination issues, etc.). This form is used to send any message or notification to incident personnel that require hard-copy delivery.

ORIGINATION: Initiated by any person on an incident.

COPIES TO: Upon completion, the HICS 213 is delivered to the original sender.

NOTES:The HICS 213 is composed of three steps:

• The message (Section 8) is completed by sender• The message is replied to in Section 10• After noting action taken, message form is returned to original sender


2 To Enter the name and position for whom the message is intended. For all individuals, use at least the first initial and last name.For Unified Command, include agency names.

3 From Enter the name and position of the individual sending the General Message. For all individuals, use at least the first initial and last name. For Unified Command, include agency names.

4 Subject Enter the subject of the message.

5 Date Enter the date (m/d/y) of the message.

6 Time Enter the time (24-hour clock) of the message.

7 Priority Enter the priority of the message or request.

8 Message Enter the content of the message.

9 Approved by Enter the name and signature of the person approving t h e message, if necessary.

10 Reply / Action Taken The intended recipient will enter a reply and/or action taken to the message and return it to the originator.

11 Replied by Enter the name, signature of the person replying to the message, and Hospital Incident Management Team (HIMT) position. Enter date (m/d/y), time prepared (24-hour clock), and facility.

HICS 2014

HICS 214 - ACTIVITY LOG


DATE: FROM: __ TO: ___

TIME: FROM: ___ TO:

3. Name 4. Hospital Incident Management Team (H IMT) Position

5. Activity LogDATE / TIME NOTABLE ACTIVITIES

6. Prepared byPRINT NAME: SIGNATURE:


Purpose: Provides documentation for basic incident activity and details of notable activitiesOrigination: Any Hospital Incident Management Team (HIMT) personnel Copies to: Documentation Unit Leader


HICS 214 - ACTIVITY LOG

PURPOSE: The HICS 214 - Activity Log records details of notable activities for any Hospital Incident Management Team (HIMT) position. These logs provide basic documentation of incident activity, and a reference for any After Action Report (AAR). Personnel should document how relevant incident activities are occurring and progressing, or any notable activities, actions taken and decisions made.

ORIGINATION: Initiated and maintained by personnel in HIMT positions as it is needed or appropriate.

COPIES TO: A completed HICS 214 must be submitted to the Documentation Unit Leader. Individuals may retain a copy for their own records.

NOTES: Multiple pages can be used if needed. If additional pages are needed, use a blank HICS214 and repaginate as needed. Additions may be made to the form to meet the organization’s needs.



3 Name Print the name of the person for whom the activities are being documented.

4 HIMT Position Enter the Hospital Incident Management Team (HIMT)position for which the activities are being documented.

5 Activity Log Enter the time (24-hour clock) and briefly describe individual notable activities. Note the date (m/d/y), as well as if the operational period covers more than one day.Activities described may include notable occurrences or events such as task assignments, task completions, injuries, difficulties encountered, information received, etc.This block can also be used to track personal work activities by adding columns such as “Action Required,” “Delegated To,” “Status,” etc.


HICS 2014

HICS 215A - INCIDENT ACTION PLAN (IAP) SAFETY ANALYSIS


DATE: FROM: _ TO: _

TIME: FROM: _ TO: _____ _

3. Hazard Mitigation

3a. Potential / Actual Hazards 3b. Affected Section / Branch / Unit and Location

3c. Mitigations 3d. Mitigation Completed(

Initials/Date/Time)

4. Prepared bySafety Officer PRINT NAME: _ SIGNATURE:

DATE/TIME: _______ FACILITY:

5. Approved byIncident Commander PRINT NAME: SIGNATURE:

DATE/TIME: FACILITY:

Purpose: Operational risk assessment to prioritize hazards, safety, and health issues, and to assign mitigation actionsOrigination: Safety OfficerCopies to: Planning Section Chief for Incident Action Plan (IAP) and Documentation Unit Leader


HICS 215A - INCIDENT ACTION PLAN (IAP) SAFETY ANALYSIS

PURPOSE: The purpose of the HICS 215A - Incident Action Plan (IAP) Safety Analysis is to record the findings of the Safety Officer after completing an operational risk assessment and toidentify and resolve hazard, safety, and health issues. When the safety analysis is completed, theform is used to help prepare the Operations Briefing.

ORIGINATION: Prepared by the Safety Officer during the IAP cycle. For those assignments involving risks and hazards, mitigation actions should be developed to safeguard responders. Appropriate incident personnel should be briefed on the hazards, mitigations, and related measures.

COPIES TO: Duplicate and attach as part of the IAP. All completed original forms must be given to theDocumentation Unit Leader.

NOTES: Issues identified in the HICS 215A should be reviewed and updated each operational period.If additional pages are needed, use a blank HICS 215A and repaginate as needed. Additions may be made to the form to meet the organization’s needs.




3 Hazard Mitigation

3a. Potential / ActualHazards

List the types of hazards and/or risks likely to be encountered by personnel or resources at the incident area relevant to the work assignment.

3b. Affected Section / BranchUnit and Location

Reference the affected sections, branches, units and the location of the hazards.

3c. Mitigations List actions taken to reduce risk for each hazard indicated (e.g., restricting access, proper PPE for identified risk).

3d. Mitigation Completed Enter the initials, date, and time when the mitigation is implemented or the hazard no longer exists.

4 Prepared bySafety Officer


5 Approved byIncident Commander

Enter the name and signature of the person approving the form. Enter date (m/d/y), time prepared (24-hour clock), and facility.

HICS 2014

HICS 221- DEMOBILIZATION CHECK-OUT


DATE: FROM: TO:

TIME: FROM: TO:

3. Section Demobilization ChecksUse as positions and resources are demobilized. The position and the resources may only be released when the checked boxesbelow are signed off, all equipment is serviced and returned, and all paperwork turned in to the Documentation Unit Leader. Respective Section Chiefs must initial their sections showing approval for demobilization.

COMMAND STAFF

INCIDENT COMMANDER REM ARK S INITIALS

All units, branches, and sections have been demobilized.

All paperwork has been gathered for review and development of After Action Report.

Final message to staff, media, and stakeholders has been developed and disseminated.

All clinical operations have returned to normal or pre-incident status.

Hospital Command Center and Emergency Operations Plan are deactivated.

PUBLIC INFORMATION OFFICER REMARKS INITIALS

Final media briefing is developed, approved, and disseminated.

Final staff and patient briefings are developed, approved, and disseminated.

Social media is updated with current status.

LIAISON OFFICER REMARKS INITIALS

All stakeholders and external partners are notified of Hospital Command Center deactivation/return to normal operations.

SAFETY OFFICER REMARKS INITIALS

Final safety review of facility is completed and documented.

All potential hazards have been addressed and resolved.

All sites/hazards have been safely mitigated/repaired and are ready to be used.

Appropriate regulatory agencies are notified.

All safety specific paperwork is completed and submitted.

MEDICAL / TECHNICAL SPECIALIST (TITLE) REMARKS INITIALS

Position-specific roles and responsibilities have been deactivated.

Response-specific paperwork is completed and submitted toDocumentation Unit Leader.







Purpose: Ensure all resources and supplies used in response and recovery are returned to pre-incident statusOrigination: Hospital Incident Management Team (HIMT) personnel designated by Incident CommanderCopies to: Command Staff, Section Chiefs, and Documentation Unit Leader

HICS 221| Page 1 of 4


OPERATIONS SECTION

STAGING AREA REMARKS INITIALS

All supplies and equipment staged for response are returned to storage or pre-response state.

All personnel are debriefed and returned to daily work site.

MEDICAL CARE BRANCH REMARKS INITIALS

All procedures and appointments are rescheduled.

All evacuated patients have been repatriated and family members notified.

All clinical information/procedures/interventions have been documented in the electronic medical record.

Alternate care sites have been deactivated and physical sites returned to pre-response operations.

Medical supplies and equipment utilized in the response have been returned to pre-response state.

Staffing patterns have returned to pre-response state.

All units within the branch are debriefed and deactivated.

INFRASTRUCTURE BRANCH REMARKS INITIALS

All damage assessments are completed and final report submitted to Operations andPlanning Section Chiefs.

Repairs to infrastructure and equipment are complete or a new state of readiness is established by Operations Section Chief.

Utility services are in pre-response state.

Resupply of critical resources is underway.

All units within the branch are debriefed and deactivated.

SECURITY BRANCH REMARKS INITIALS

Facility and/or campus lockdown is suspended.

Hospital personnel used to augment security staff are debriefed and demobilized.

Additional security measures used in the response are now discontinued.

All units within branch are debriefed and deactivated.

HAZMAT BRANCH REMARKS INITIALS

Decontamination operations are concluded and all supplies, equipment, and personnel are returned to a pre-response state.

Water collected in decontamination operations is collected and disposed of safely.

Authorities are notified of the decon operations, including water collection.

Personnel involved in decon are referred to Employee Health for surveillance.


BUSINESS CONTINUITY BRANCH REMARKS INITIALS

All supplies and equipment used in relocated services have been returned.

Interruptions in data entry have been resolved and documentation recovered.





PATI EN T FA M I LY ASSI STAN CE BRAN CH REM ARK S INITIALS

All supplies and equipment used in relocated services have been returned.


PLANNING SECTION

RESOURCES UNIT REMARKS INITIALS

All tracking forms are complete and submitted to Documentation Unit Leader.

All tracking tools are demobilized and returned to storage.

SITUATION UNIT REMARKS INITIALS

All tracking forms are complete and submitted to Documentation Unit Leader.

All tracking tools are demobilized and returned to storage.

DOCUMENTATION UNIT REMARKS INITIALS

All paperwork created or used in the response has been submitted.

All paperwork is catalogued and correlated for review.

DEMOBILIZATION UNIT REMARKS INITIALS

All paperwork, including the approved Demobilization Plan, is submitted toDocumentation Unit Leader.

LOGISTICS SECTION

SERVICE BRANCH REMARKS INITIALS

All communications equipment is returned to readiness.1. Radios and batteries are placed in charging stations.2. Voice and text messages are reviewed and deleted.3. Extra disaster telephones are returned to storage.4. Satellite phones are returned and placed on chargers.5. Hospital Command Center communication equipment is returned to storage.

All deployed information technology (IT) equipment is returned and inspected;all event specific data is removed and archived.

All food/water stores are returned to daily operations levels.

Disposable food preparation and delivery supplies are removed from service.


SUPPORT BRANCH REMARKS INITIALS

Supplies and equipment used in response are inspected, cleaned, and returned to storage or daily use.

All equipment requiring calibration or repair is entered into preventive maintenance/service program.


FINANCE / ADMINISTRATION SECTION

TIME UNIT REMARKS INITIALS

All timesheets and other documentation tools are collected and provided toDocumentation Unit Leader.

PROCUREMENT UNIT REMARKS INITIALS

All order forms, expense sheets, and other documentation tools are collected and provided to Documentation Unit Leader.




COMPENSATION / CLAIMS UNIT REMARKS INITIALS

All timesheets and other documentation tools are collected and provided toDocumentation Unit Leader.

All insurance forms are completed and submitted per policy.

COST UNIT REMARKS INITIALS

All time sheets and other documentation tools are collected and provided toDocumentation Unit Leader.

All expense reports are completed.

All outstanding expenses, bills, purchase orders, check cards, bank cards have been resolved.

ALL POSITIONS REMARKS INITIALS

All paperwork generated during the response and recovery is submitted to theDocumentation Unit Leader.

All response and recovery equipment related to your role has been repaired, charged, restocked, and returned to storage.

Daily supervisor is notified of your deactivation and return to normal duties.


POSITION: FACILITY:

DATE/TIME:




PURPOSE: The HICS 221 - Demobilization Check-Out ensures that resources utilized during response and recovery has been returned to pre-incident status.

ORIGINATION: The HICS 221 is completed by Hospital Incident Management Team (HIMT)personnel designated by the Incident Commander.

COPIES TO: Delivered to the applicable Command Staff and Section Chief(s) for review and approval then forwarded to the Demobilization Unit or the Planning Section. All completed original forms must be given to the Documentation Unit Leader. Personnel may request to retain a copy of the HICS 221.

NOTES: HIMT personnel are not released until form is complete and signed by their Section Chief. If additional pages are needed, use a blank HICS 221 and repaginate as needed. Additions may be made to the form to meet the organization’s needs.




3 Section DemobilizationChecks

As demobilization actions are taken, check off each appropriate box (or indicate “N/A”), and ensure Section Chief signs or initials approval before resource is released.

4 Prepared by Enter the name, Hospital Incident Management Team (HIMT) position, and signature of the person preparing the form. Enter date (m/d/y), time prepared (24-hour clock), and facility.

HICS 2014

HICS 251 – FACILITY SYSTEM STATUS REPORTDepartment Use

1. Incident Name 2. Time Completed: (# )

DATE: FROM: TO:

TIME: FROM: TO:

3. Name of Department / Unit Reporting Status Below Contact Number:

4. System 5. Status 6. Comments If not fully functional, give location, reason, and estimated time/resources for necessary repair. Identify who reported or inspected.

PowerRoutine and emergency Fully functional

Partially functional

Nonfunctional

N/A

Lighting Fully functional


Nonfunctional

N/A

Water Fully functional


Nonfunctional

N/A

Sewage / Toilets Fully functional


Nonfunctional

N/A

Nurse Call System Fully functional


Nonfunctional

N/A

Medical Gases / Oxygen Fully functional


Nonfunctional

N/A

CommunicationsIT systems, telephones, pagers

Fully functional


Nonfunctional

N/A

7. Remarks (Cracked walls, broken glass, falling light fixtures, etc.)



Purpose: Determine facility operating statusOrigination: Infrastructure Branch DirectorCopies to: Operations Section Chief, Business Continuity Branch Director, Planning Section Chief,

Safety Officer, Liaison Officer, Materiel Tracking Managers, and Documentation Unit Leader HICS 251 | Page 1 of 1

HICS 251 – FACILITY SYSTEM STATUS REPORT


DATE: FROM: _________ TO:

TIME: FROM: _ TO:

3. Name of Facility / Building Reporting Status Below

4. System 5. Status 6. Comments If not fully functional, give location, reason, and estimated time/resources for necessary repair. Identify who reported or inspected.

COM M UNICATIONS

Fax Fully functional


Nonfunctional

N/A

Information Technology System Email, registration, patient records, time card system

Fully functional


Nonfunctional

N/A

Nurse Call System Fully functional


Nonfunctional

N/A

Overhead Paging Fully functional


Nonfunctional

N/A

Paging SystemCode teams, standard paging

Fully functional


Nonfunctional

N/A

Radio EquipmentFacility handheld, 2-way radios, antennas

Fully functional


Nonfunctional

N/A

Radio EquipmentEMS, local health department, other externalPartner

Fully functional


Nonfunctional

N/A

Radio EquipmentAmateur radio

Fully functional


Nonfunctional

N/A

Satellite Phones Fully functional


Nonfunctional

N/A




Telephone SystemPrimary

Fully functional


Nonfunctional

N/A

Telephone SystemProprietary

Fully functional


Nonfunctional

N/A

Telephone SystemBack-up

Fully functional


Nonfunctional

N/A

Internet Fully functional


Nonfunctional

N/A

Video-TelevisionCable

Fully functional


Nonfunctional

N/A

INFRASTRUCTURE

Campus AccessRoadways, sidewalks, bridge

Fully functional


Nonfunctional

N/A

Fire Detection System Fully functional


Nonfunctional

N/A

Fire Suppression System Fully functional


Nonfunctional

N/A

Food Preparation Equipment Fully functional


Nonfunctional

N/A

Ice Machines Fully functional


Nonfunctional

N/A




Laundry/Linen Service Equipment Fully functional


Nonfunctional

N/A

Structural ComponentsBuilding integrity

Fully functional


Nonfunctional

N/A

(Note cracked walls, loose masonry, hanging light fixtures, broken windows)

PATIENT CARE

Decontamination SystemIncluding containment

Fully functional


Nonfunctional

N/A

Digital Radiography System, RoutineDiagnosticsPACS, CT, MRI, other

Fully functional


Nonfunctional

N/A

Steam/Chemical Sterilizers Fully functional


Nonfunctional

N/A

Isolation RoomsPositive/negative air

Fully functional


Nonfunctional

N/A

SECURITY

Facility Lockdown SystemsDoor/key card access

Fully functional


Nonfunctional

N/A

Campus SecurityExternal panic alarms

Fully functional


Nonfunctional

N/A

Campus SecuritySurveillance cameras

Fully functional


Nonfunctional

N/A

Campus SecurityTraffic controls

Fully functional


Nonfunctional

N/A


Safety Officer, Liaison Officer, Materiel Tracking Managers, and the Documentation Unit Leader



Campus SecurityLighting

Fully functional


Nonfunctional

N/A

Panic AlarmsInternal and other reporting devices

Fully functional


Nonfunctional

N/A

UTILITIES

Electrical PowerPrimary service

Fully functional


Nonfunctional

N/A

Electrical PowerBackup generator

Fully functional


Nonfunctional

N/A

Fuel Storage Fully functional


Nonfunctional

N/A

(Note amount on hand)

Sanitation Systems Fully functional


Nonfunctional

N/A

Water Fully functional


Nonfunctional

N/A

Natural Gas/Propane Fully functional


Nonfunctional

N/A

Air Compressor Fully functional


Nonfunctional

N/A

Elevators/Escalators Fully functional


Nonfunctional

N/A





Hazardous Waste ContainmentSystem

Fully functional


Nonfunctional

N/A

Heating, Ventilation, and AirConditioning (HVAC)

Fully functional


Nonfunctional

N/A

Oxygen Fully functional


Nonfunctional

N/A

(Note bulk, H tanks, E tanks, Reserve supply status)

Medical Gases, Other Fully functional


Nonfunctional

N/A

(Note reserve supply status)

Pneumatic Tube Fully functional


Nonfunctional

N/A

Steam Boiler Fully functional


Nonfunctional

N/A

Sump Pump Fully functional


Nonfunctional

N/A

Well Water System Fully functional


Nonfunctional

N/A

Vacuum (f or patient use) Fully functional


Nonfunctional

N/A

Water Heater and Circulators Fully functional


Nonfunctional

N/A





External Lighting Fully functional


Nonfunctional

N/A

External StorageEquipment

Fully functional


Nonfunctional

N/A

External StorageVehicles

Fully functional


Nonfunctional

N/A

Parking Structures, Lots Fully functional


Nonfunctional

N/A

(Power, panic alarms, access, egress, lighting)

Landing ZonePads, lighting, fuel source

Fully functional


Nonfunctional

N/A

7. Remarks (Cracked walls, broken glass, falling light fixtures, etc.)



Purpose: Determine facility operating status Origination: Infrastructure Branch Director Copies to: Operations Section Chief, Business Continuity Branch Director, Planning Section Chief, Safety Officer, Liaison Officer, Materiel Tracking Managers, and the Documentation Unit Leader



PURPOSE: The HICS 251-Facility System Status Report is used to record the status of various critical facility systems and infrastructure. The HICS 251 provides the Planning and Operations Sections with information about current and potential system failures or limitations that may affect incident response and recovery.

ORIGINATION: Completed by the Operations Section Infrastructure Branch Director with input from facility personnel.

COPIES TO: Delivered to the Situation Unit Leader, with copies to the Operations Section Chief, Business Continuity Branch Director, Planning Section Chief, Safety Officer, Liaison Officer, Materiel Tracking Managers, and the Documentation Unit Leader.

NOTES: The Infrastructure Branch conducts the survey and correlates results. Individual department managers may also be tasked to complete an assessment of their areas and provide the information to the Infrastructure Branch. If additional pages are needed, use a blank HICS 251 and repaginate as needed. Additions and deletions may be made to the form to meet the organization’s needs.



3 Name of FacilityReporting Status

Enter the name of the facility.

4 System System type listed in form.

5 Status Fully functional: 100% operable with no limitationsPartially functional: Operable or somewhat operable with limitationsNonfunctional: Out of commissionN/A: Not applicable, do not have

6 Comments Comment on location, reason, and estimates for necessary repair of any system that is not fully operational. If inspection is completed by someone other than as defined by policy or procedure, identify that person in the comments.

7 Remarks Note any overall facility-wide assessments or future potential issues such as skilled staffing issues, fuel duration, plans for repairs, etc.


HICS 2014

HICS 252 - SECTION PERSONNEL TIME SHEET


DATE: FROM: _____ TO: _____

TIME: FROM: _____ TO: _____

3. Time Record

# EMPLOYEE (E) VOLUNTEER (V)NAME (PRINT) E / V EMPLOYEE NUMBER RESPONSE FUNCTION

SECTION / ASSIGNMENT DATE / TIME IN DATE / TIME OUT TOTAL HOURS

SIGNATURE(TO VERIFY TIMES)

1

2

3

4

5

6

7

8

9

10

4. Prepared byPRINT NAME: SIGNATURE: _______________________________________________________________________

DATE/TIME: _______________________________________________________________________ FACILITY: __________________________________________________________________________

Purpose: Record each section’s personnel time and activitiesOrigination: Hospital Incident Management Team (HIMT) personnel as directed by Incident Commander or Section ChiefCopies to: Time Unit Leader


HICS 252 - SECTION PERSONNEL TIME SHEET

PURPOSE: The HICS 252 - Personnel Time Sheet is used to record each section’s personnel time and activities.

ORIGINATION: Section Chiefs are responsible for ensuring that personnel complete the form.

COPIES TO: Provided to the Finance/Administration Section Time Unit Leader every 12 hoursor every operational period (as directed by the Incident Commander). A copy is given to theDocumentation Unit Leader.




3 Time RecordEmployee (E) / Volunteer (V) Name (Print)

Print the full name of the personnel assigned.

E / V Enter employee (E) or volunteer (V).Employee Number If employee of the organization, fill in employee number.

Response Function Section / Assignment

Enter assignment being assumed.

Date / Time In Enter time started in assignment.Date / Time Out Enter time ended in assignment.Total Hours Enter total number of hours in assignment.

Signature Employee/volunteer signature verifying that times are correct.


HICS 2014

HICS 253 - VOLUNTEER REGISTRATION


DATE: FROM: TO: _

TIME: FROM: TO:

3. Registration Information

NAME(LAST NAME, FIRST NAME)

CERTIFICATION / LICENSE AND NUMBER

ID NUMBER (DRIVERS LICENSE

OR SSN)

ADDRESS(CITY, STATE, ZIP)

CONTACT INFO(PHONE, CELL)

BADGE ISSUED

BADGE RETURNED

TIME IN /

OUTSIGNATURE

4. Prepared by PRINT NAME: ____________________________________________________________________ SIGNATURE: ____________________________________________________________________________

DATE/TIME ______________________________________________________________________ FACILITY: _______________________________________________________________________________

Purpose: To document volunteer information for each operational periodOrigination: Labor Pool and Credentialing Unit LeaderCopies to: Time Unit Leader, Personnel Tracking Manager, and Documentation Unit Leader


HICS 253 - VOLUNTEER REGISTRATION

PURPOSE: The HICS 253 -Volunteer Registration is used to document volunteer sign in and sign out for each Operational Period.

ORIGINATION: Completed by the Logistics Section Labor Pool and Credentialing Unit Leader.

COPIES TO: Copies are distributed to the Time Unit Leader, Personnel Tracking Manager, andDocumentation Unit Leader.




3 Registration Information

Name Enter the full name of volunteer.

Certification / License andNumber

If volunteer holds a certification or license, enter type and number.

ID Number Enter a Driver’s License number or Social Security Number.

Address Enter address.

Contact Info Enter phone number.

Badge Issued Enter yes or no, and number if used.

Badge Returned Enter yes or no.

Time In / Out Time (24-hour clock) volunteer was in and out.

Signature Signature of volunteer verifying that information is correct.


HICS 2014

HICS 254 – DISASTER VICTIM / PATIENT TRACKING


DATE: FROM: TO:

TIME: FROM: _ TO:

3. Area (Triage or Specific Treatment Area)

FIELD TAG NUMBER

MEDICAL RECORD NUMBER

NAME(LAST NAME, FIRST NAME)

SEX(M/F)

DOB / AGETRIAGE CATEGORY

IMMEDIATE DELAYED MINOR

EXPECTANTEXPIRED

LOCATION / TIME OF PROCEDURES(CT, X-RAY, ETC.)

DISPOSITION / TIME (D) DISCHARGE (A)

ADMIT(S) SURGERY (T) TRANSFER (M) MORGUE



Purpose: Records the triage, treatment, and location of victims/patientsOrigination: Patient Tracking Manager or teamCopies to: Situation Unit Leader, Patient Registration Unit Leader, Planning Section Patient Tracking Manager, Medical Care Branch Director, and Documentation Unit Leader


HICS 254 - DISASTER VICTIM / PATIENT TRACKING

PURPOSE: The HICS 254 Disaster Victim / Patient Tracking records the triage, treatment, and disposition of victims/patients of the event seeking medical attention.

ORIGINATION: Completed by the Patient Tracking Manager or team members.

COPIES TO: Distributed to the Situation Unit Leader, with copies to Patient RegistrationUnit Leader, Planning Section Patient Tracking Manager, Medical Care Branch Director, and theDocumentation Unit Leader.

NOTES: The form is completed upon arrival of the first patient and updated periodically. Copies of the form are sent to the Planning Section Patient Tracking Manager each hour and at the end of each operational period until disposition of the last victim(s) are known. If additional pages are needed, use a blank HICS 254 and repaginate as needed. Additions may be made to the form to meet the organization’s needs.



3 Area Enter the triage or specific treatment area (e.g., Triage, Immediate Treatment Area).

Field Tag Number Enter field triage tag number.Medical Record Number Enter hospital medical record number if available.

Name Enter the full name of victim/patient.Sex Enter sex: M for male/F for female.DOB / Age Enter date of birth and age.

Triage Category Enter the triage category assigned to patient.Location / Time of Procedures Enter location destination and time patient leaves

triage or treatment area for a test or procedure.

Disposition / Time Enter the letter of the disposition category and time of disposition.

4 Prepared by Enter the name and signature of the personpreparing the form. Enter date (m/d/y), time prepared(24-hour clock), and facility.

HICS 2014

HICS 255 - MASTER PATIENT EVACUATION TRACKING


DATE: FROM: TO:

TIME: FROM: TO:

3. Patient Evacuation Information

PATIENT NAME Medical Record # Evacuation Triage Category IMMEDIATE DELAYED MINOR

Mode of Transport CCT ALS BLS VAN BUS CAR AIRCRAFT

Disposition DISCHARGE TRANSFER MORGUE

Accepting Hospital or Location Time hospital contacted & report given

Transfer Initiated (Time/Transport Co./ #) Medical Record Sent YES NO

Medication Sent YES NO

Family Notified YES NO

Arrival Confirmed YES NO

Admit Location FLOOR ICU ER MORGUE

Expired (time)










Expired (time)










Expired (time)










Expired (time)



Purpose: Record information concerning patient disposition during an evacuationOrigination: Situation Unit Leader or designee (Patient Tracking Manager)Copies to: Planning Section Chief, Documentation Unit Leader.


HICS 255 - MASTER PATIENT EVACUATION TRACKING

PURPOSE: The HICS 255 - Master Patient Evacuation Tracking form records the disposition of patients during a facility evacuation.

ORIGINATION: Completed by Planning Section Situation Unit Leader or designee (Patient Tracking Manager).

COPIES TO: Distributed to the Planning Section Chief and the Documentation Unit Leader.

NOTES: The form may be completed with information taken from each HICS 260 - Patient Evacuation Tracking form. If additional pages are needed, use a blank HICS 255 and repaginate as needed.



3 Patient Evacuation InformationPatient Name Enter the full name of the patient.

Medical Record # Enter medical record number.

Evacuation Triage Category Indicate the categories as defined by the facility (not necessarily the same as emergency department admitting triage system).

Mode of Transport Indicate the mode of transport or write in if not indicated.

Disposition Indicate the patient’s disposition.

Accepting Hospital or Location Enter the accepting hospital or location (e.g., AlternateCare Site, holding site).

Time hospital contacted &report given

Enter time prepared (24-hour clock).

Transfer Initiated Enter time, vehicle company, and identification number.

Medical Record Sent Indicate yes or no.

Medication Sent Indicate yes or no.

Family Notified Indicate yes or no.

Arrival Confirmed Indicate yes or no.

Admit Location Indicate the applicable site.

Expired Enter time (24-hour clock) of deceased if necessary.


HICS 2014

HICS FORM 256 - PROCUREMENT SUMMARY REPORT


DATE: FROM: TO:

TIME: FROM: __ TO:

3. Purchases

P.O. / REFERENCE NUMBER DATE / TIME ITEM / SERVICE VENDOR DOLLAR

AMOUNTREQUESTOR NAME / DEPT

(PLEASE PRINT)APPROVED BY(PLEASE PRINT)

RECEIVEDDATE / TIME

1COMMENTS

2COMMENTS

3

COMMENTS

4

COMMENTS

5

COMMENTS

6

COMMENTS

7

COMMENTS

8

COMMENTS

9

COMMENTS

PRINT NAME: SIGNATURE:4. Prepared by

DATE/TIME: _____ FACILITY: _

Purpose: Summarizes and tracks procurementsOrigination: Hospital Incident Management Team (HIMT) personnel as directed by the Procurement Unit LeaderCopies to: Finance/Administration Section Chief and Documentation Unit Leader


HICS FORM 256 - PROCUREMENT SUMMARY REPORT

PURPOSE: The HICS 256 - Procurement Summary Report summarizes and tracks procurements.It may be completed by operational period or for the whole incident duration.

ORIGINATION: Completed by the Hospital Incident Management Team (HIMT) personnel as directed by the Procurement Unit Leader.

COPIES TO: Distributed to the Finance/Administration Section Chief and the Documentation Unit Leader.




3 Purchases

P.O. / Reference number

Enter purchase order or other acquisition reference number used by the facility.

Date / Time Enter date (m/d/y) and time prepared (24-hour clock).

Item / Service Enter the item or the service purchased.

Vendor Enter the name of the vendor.

Dollar Amount Enter the dollar amount spent.

Requestor Name /Department

Enter the requestor’s name and department.

Approved By Enter whom the purchase was approved by.

Received Date / Time Enter date (m/d/y) and time (24-hour clock) the item or service was received.


HICS 2014

HICS 257 - RESOURCE ACCOUNTING RECORD


DATE: FROM: _ TO:

TIME: FROM: _ TO:

3. Resource Record

TIME ITEM / FACILITY TRACKING IDENTIFICATION NUMBER CONDITION RECEIVED FROM DISPENSED(TO/TIME)

RETURNED(DATE/TIME)

CONDITION(OR INDICATE IF NON-

RECOVERABLE)INITIALS

4. Pre pared by PRINT NAME: ____________________________________________________________________ SIGNATURE: ____________________________________________________________________

DATE/TIME: _____________________________________________________________________ FACILITY: _______________________________________________________________________

Purpose: Records the request, distribution, return, and condition of equipment and resourcesOrigination: Hospital Incident Management Team (HIMT) personnel as directed by Section ChiefsCopies to: Finance/Administration Section Chief, Resources Unit Leader, Materiel Tracking Manager, and Documentation Unit Leader

HICS 257 | Page1 of 1

HICS 257 - RESOURCE ACCOUNTING RECORD

PURPOSE: The HICS 257 - Resource Accounting Record documents the request, distribution for use, return, and condition of equipment and resources used to respond to the incident.

ORIGINATION: Completed by each Hospital Incident Management Team (HIMT) personnel as directed by SectionChiefs.

COPIES TO: Distributed to the Finance/Administration Section Chief, the Resources Unit Leader, the Materiel Tracking Manager, the original requester of the resource, and the Documentation Unit Leader.




3 Resource Record

Time Enter the time (24-hour clock) and the request received.

Item / Facility TrackingIdentification Number

Enter the item and the facility tracking identification number.

Condition Enter the condition of the item when it was received.

Received From Enter whom the item was received from.

Dispensed Enter whom the item was dispensed to and the time (24-hour clock).

Returned Enter the date (m/d/y) and time (24-hour clock) the item was returned.

Condition Enter the condition the item was in when returned or indicate if non- recoverable.

Initials Enter initials of person processing item.


HICS 2014

HICS 258 - HOSPITAL RESOURCE DIRECTORY


DATE: FROM: TO:

TIME: FROM: TO: _

3. Contact Information

COMPANY / AGENCY COMPANY / AGENCY / NAME(24/7 CONTACT) TELEPHONE ALTERNATE TELEPHONE EMAIL FAX RADIO

Agency f or Toxic Substances andDisease Registry (ATSDR)Air transport: helicopter orfixed wingAmbulance, hospital-based

Ambulance, private

Ambulance, public safety

American Red Cross

Automated Teller Machine (ATM) (Onsite)Biohazard/Waste company

Buses

Cab (Taxi)

Centers f or Disease Control andPrevention (CDC)

Clinics

Coroner/Medical Examiner

Dispatcher, 911

Emergency Management Agency

EMS Agency/Authority

Emergency Operations Center(EOC), LocalEmergency Operations Center(EOC), State

Purpose: List resources to contact during an IncidentOrigination: Resource Unit LeaderCopies to: Command Staff, Section Chiefs, and Documentation Unit Leader




Engineers: HVAC

Engineers: mechanical

Engineers: seismic

Engineers: structural

Environmental Protection Agency(EPA)

Epidemiologist

Federal Bureau of Investigation (FBI)

Fire Department

Food service (Note if vendor, onsite, or emergency)

Fuel distributor

Fuel trucks

Funeral homes/mortuary services

Generators

HazMat Team

Health department, local

Health department, state

Heavy equipment (e.g., backhoes, snowplow, etc.)

Home health service

Home repair/construction supplies

1.

2.





Hospice

Hospitals

1.

2.

3.

4.

Hotel/motel

Housing, temporary

Ice, commercial

Laboratory Response Network

Laundry/linen service

Law Enforcement

Lighting

Long term care facilities

1.

2.

3.

Media: print

Media: print

Media: radio

Media: radio





Media: TV

Media: TV

Media: TV

Medical gases

Medical supply

1.

2.

Medication, distributor

1.

2.

Pharmacy, commercial

1.

2.

3.

Poison Control Center

Portable toilets

Radios: amateur radio

Radios: satellite

Radios: handheld or 2-way

Regional Medical Health Coordinator





Repair Services

Beds

Biomedical devices

Elevators

Gardeners/landscapers

Glass

Medical equipment

Oxygen devices

Radios

Roadways/sidewalks

Salvation Army

Shelter Sites

Surge Facilities

Traffic Control/Department ofTransportationTrucks

Refrigeration

Towing

Moving

Utilities

Gas





Utilities

Gas/Electricity

Sew age

Telephone

Water, municipal

Vending Machines

Ventilators

Water: non-potable

Water: potable

Other

Other

Other

Other

4. Date Last Updated

5. Prepared by PRINT NAME: _ SIGNATURE:





PURPOSE: The HICS 258 - Hospital Resource Directory lists all methods of contact for hospital resources for an incident.

ORIGINATION: Completed by the Planning Section Resources Unit Leader p r i o r to an incident (when possible) or at the incident onset, and continually updated throughout an incident.

COPIES TO: Distributed to the Command and General Staff including the DocumentationUnit Leader, and posted as necessary.

NOTES: If this form contains sensitive information such as cell phone numbers, it should be clearly marked in the header that it contains sensitive information and is not for public release. If additional pages are needed, use a blank HICS 258 and repaginate as needed. Additions and deletions may be made to the form to meet the organization’s needs.



3 Contact InformationCompany / Agency Type of company or agency.Company / Agency / Name List the name of the company/agency. List the name of the

point of contact if available.

Telephone Enter the telephone number.Alternate Telephone Enter the alternate telephone number.

Email Enter the email, if available.Fax Enter the fax number.Radio Enter the radio frequency if appropriate.

4 Date Last Updated If the document is completed prior to an incident, the last update should be entered (m/d/y). The directory should be updated at least annually.


HICS 2014

HICS 259 - HOSPITAL CASUALTY / FATALITY REPORT


DATE: FROM: TO:

TIME: FROM: TO:

3. Number of Casualties / Fatalities

ADULT PEDIATRIC (<18 YRS OLD) TOTAL COMMENTS

Patients seen

Admitted

Critical Care

Medical / Surgical

Other

Other

Other

Discharged

Transferred

Morgue

Waiting to be seen

4. Prepared by PRINT NAME: ___________________ _________________ SIGNATURE: ____________________________________________________________

DATE/TIME: _______________________________________________________________________________ FACILITY: _____

Purpose: Record the total numbers of adult and pediatric patients seen, admitted, discharged, transferred, expired, and waiting to be seenOrigination: Patient Tracking Manager or teamCopies to: Command Staff, Section Chiefs, and Documentation Unit Leader


HICS 259 - HOSPITAL CASUALTY / FATALITY REPORT

PURPOSE: The HICS 259 - Hospital Casualty/Fatality Report is used to record the total numbers of adult and pediatric patients seen, admitted (by bed type), discharged, transferred, expired, and waiting to be seen for each operational period.

ORIGINATION: The HICS 259 is prepared by the Planning Section Patient Tracking Manager or team prior to the Operations Briefing in the next operational period.

COPIES TO: Copies are distributed to the Command staff, Section Chiefs, and the DocumentationUnit Leader.




3 Number of Casualties / Fatalities

Patients seen Enter total number of patients seen in either the adult or pediatric column.

Admitted Enter total number of patients admitted in either the adult or pediatric column.

Critical Care Enter total number of patients admitted in either the adult or pediatric column.

Medical / Surgical Enter total number of patients admitted in either the adult or pediatric column.

Other Enter other needed categories (i.e., burn, pediatric, labor and delivery, forensic, psychiatric) in either the adult or pediatric column.

Discharged Enter total number of patients discharged in either the adult or pediatric column.

Transferred Enter total number of patients transferred in either the adult or pediatric column.

Morgue Enter total number of patients expired in either the adult or pediatric column.

Waiting to be seen Enter total number of patients still waiting to be seen by physician in either the adult or pediatric column.


HICS 2014

HICS 260 - PATIENT EVACUATION TRACKING FORM

1. Date 2. From (Unit)

3. Patient Name 4. DOB 5. Medical Record Number

6. Diagnosis 7. Admitting Physician

8. Family Notified YES NO NAME: CONTACT INFORMATION: _

9. Mode of Transport 10. Accompanying Equipment (check those that apply)

Hospital Bed

Gurney

Wheelchair

Ambulatory

Other:

IV Pump(s)

Oxygen

Ventilator

Chest Tube(s)

Other:

Isolette/WarmerTraction

Monitor

A-Line/SwanOther:

Foley Catheter Halo-Device Cranial Bolt/Screw

Intraosseous DeviceOther:

11. Special Needs

12. Isolation YES NO TYPE: REASON:

13. Evacuating Clinical Location 14. Arriving Location

ROOM # TIME ROOM # TIME

ID BAND CONFIRMED

BY:YES NO ID BAND CONFIRMED

BY:YES NO

MEDICAL RECORD SENT YES NO MEDICAL RECORD RECEIVED YES NO

BELONGINGSWITH PATIENT LEFT IN ROOM

NONE

BELONGINGS RECEIVEDYES NO

VALUABLESWITH PATIENT LEFT IN SAFE

NONE

VALUABLES RECEIVEDYES NO

MEDICATIONSWITH PATIENT LEFT ON UNIT

PHARMACY

MEDICATIONS RECEIVEDYES NO

PEDS / INFANTS PEDS / INFANTS

BAG/MASK WITH TUBING SENT YES NO BAG/MASK /W TUBING RCVD YES NO

BULB SYRINGE SENT YES NO BULB SYRINGE RECEIVED YES NO

15. Transferring to another Facility / LocationTIME TO STAGING AREA TIME DEPARTING TO RECEIVING FACILITY

Destination

TRANSPORTATION AMBULANCE. # AGENCY HELICOPTER OTHER

ID BAND CONFIRMED YES NO BY

DEPARTURE TIME:

16. Prepared byPRINT NAME: SIGNATURE: _

DATE/TIME: ________ FACILITY:

Purpose: Detail and account for patients transferred to another facility Origination: Inpatient/Outpatient Unit Leader or Casualty Care Unit Leader Copies to: Patient Tracking Manager, Medical Care Branch Director,

evacuating clinical location, and Documentation Unit Leader

HICS 260 I Page 1 of 1

HICS 260 - PATIENT EVACUATION TRACKING FORM

PURPOSE: The HICS 260 - Patient Evacuation Tracking Form documents details and account for patients transferred to another facility.

ORIGINATION: Completed by the Operations Section as appropriate: the Inpatient Unit Leader, the Outpatient Unit Leader, or the Casualty Care Unit Leader, depending on where the identified patient is located.

COPIES TO: The original is kept with the patient through actual evacuation. Copies are distributed to the Patient Tracking Manager, the Medical Care Branch Director, the evacuating clinical location, and the Documentation Unit Leader.

NOTES: The information on this form may be used to complete HICS 255, Master Patient Evacuation Tracking Form. Additions or deletions may be made to the form to meet the organization’s needs.


1 Date Enter the date of the evacuation.

2 From Enter the Unit the patient is leaving from.

3 Patient Name Enter the patient’s full name.

4 DOB Enter the patient’s date of birth (DOB).

5 Medical RecordNumber

Enter the patient’s medical record number.

6 Diagnosis Enter the primary diagnosis/diagnoses.

7 Admitting Physician Enter the name of the patient’s admitting physician.

8 Family Notified Check yes or no; enter family contact information.

9 Mode of Transport Identify mode of transportation needed.

10 AccompanyingEquipment

Check appropriate boxes for any equipment being transferred with the patient.

11 Special Needs Indicate if the patient has special needs, assistance, or requirements.

12 Isolation Indicate if isolation is required, the type, and the reason.

13 Evacuating ClinicalLocation

Fill in information and check boxes to indicate originating room and what was sent with the patient (records, medications, and belongings).

14 Arriving Location Fill in information and check boxes to indicate patient’s arrival at the new location and whether materials sent with the patient were received.

15 Transferring to another Facility / Location

Document arrival and departure from the staging area, confirmation of ID band, and type of transportation used.


HICS 2014